Managing Severe Hypoxic Respiratory Failure in COVID-19.

Purpose of Review: Adult respiratory distress syndrome is a life-threatening complication from severe COVID-19 infection resulting in severe hypoxic respiratory failure. Strategies at improving oxygenation have evolved over the course of the pandemic. Recent Findings: Although non-invasive respiratory support reduces the need for intubation, a significant number of patients with COVID-19 progress to invasive mechanical ventilation. Once intubated, a lung protective ventilation strategy should be employed that limits tidal volumes to 6 ml/kg of predicted body weight and employs sufficient positive end-expiratory pressure to maximize oxygen delivery while minimizing the fraction of inspired oxygen. Intermittent prone positioning is effective at improving survival, and there is a growing body of evidence that it can be safely performed in spontaneously breathing patients to reduce the need for invasive mechanical ventilation. Inhaled pulmonary vasodilators have not been shown to improve survival or cost-effectiveness in COVID-19 and should be used selectively. Summary: Finally, the best outcomes are likely achieved at centers with experience at severe ARDS management and protocols for escalation of care.

Vaccine Hesitancy.

Purpose of Review: The recent COVID-19 pandemic has caused over 800,000 deaths in the USA as of this writing. Remarkable, several effective vaccines have been developed within 1 year of the occurrence of the pandemic's outbreak in the USA. Recent Findings: Although the vaccine has proven to be remarkably effective in preventing hospitalization and death, the number of unvaccinated persons in the USA who are eligible for the vaccine remains over 35%. Summary: Unvaccinated persons pose a risk for vaccine mutation and prolongation of the pandemic, with its attendant quarantines and societal shutdowns. The ability of clinicians to address this problem remains unclear in a population suspicious of science and of the health care community.

Recent Developments in Infectious Disease Chemotherapy: Review for Emergency Department Practitioners 2020.

PURPOSE OF REVIEW: We discuss and review new antimicrobials for treatment of bacterial, viral, fungal, and parasitic infections with indications, contraindications, and side effects for each. We will also review new information and indications on older agents that are relevant to clinical practice. Many of them may be unfamiliar to Emergency Physicians given their newness and at times hospital restrictions on their use. We also review some new promising agents that are not yet in the clinical pipeline. RECENT FINDINGS: As new antibiotics become available for clinicians to use, new information becomes available with respect to the drugs' indications, efficacy, pathogen resistance, drug-drug interactions, and side effects. SUMMARY: This article provides Emergency Department clinicians with a useful summary with new information on antibiotic use and recent research into agents which may become available.

EMS Disease Exposure, Transmission, and Prevention: a Review Article.

PURPOSE OF REVIEW: This article aims to review recent literature regarding the risks of disease exposure to pre-hospital providers and the patients they serve, as well as the challenges they face in minimizing transmission and exposure. RECENT FINDINGS: Many studies continue to show poor compliance with consistent universal precautions, as well as proper hand hygiene. Vaccination rates are suboptimal despite attempts to encourage compliance. With the spread of multi-drug resistant organisms, new techniques of decontamination need to be investigated. SUMMARY: There remains a general lack of information and studies regarding the risks of disease exposure and transmission to EMS providers despite the significance hazards their profession can pose. However, there remains a continued theme throughout the majority of EMS and pre-hospital studies, demonstrating that hand washing and consistent use of personal protective equipment remains a persistent, preventable means of disease exposure and transmission.

A multifaceted quality improvement program improves endotracheal tube confirmation documentation in the emergency department.

Confirmation of endotracheal tube (ETT) position is an essential part of emergency department (ED) airway care. The study team evaluated the effect of a multifaceted quality improvement initiative on improving confirmation documentation rates. Rates of documentation of appropriate methods of ETT position confirmation were better for patients undergoing ETT placement in the study site ED than for those arriving already intubated (103/127 [81.1%] vs 19/71 [26.8%]; relative risk [RR] = 3.03; 95% confidence interval [CI] = 2.04 to 4.49). Overall rates of documentation of appropriate methods of ETT position confirmation were higher after the intervention (557/758 [73.5%] vs 122/198 [61.6%]; RR = 1.19; 95% CI = 1.06 to 1.34), with a greater increase among the group presenting to the ED with an ETT already placed (116/259 [44.8%] vs 19/71 [26.8%]; RR = 1.67; 95% CI = 1.11 to 2.51) compared with those intubated in the study site ED (103/127 [81.1%] vs 441/499 [88.4%]; RR = 0.92; 95% CI = 0.8389 to 1.0039).

Emergency department experience with nonoral contrast computed tomography in the evaluation of patients for appendicitis.

STUDY OBJECTIVES: The American College of Radiology lists oral contrast as an institution-specific option in the evaluation of right lower quadrant pain. Previous literature indicates that an accurate assessment for appendicitis can be made by CT using IV contrast alone, with significant time savings from withholding oral contrast. Before 2010, the protocol for CT use in the evaluation of possible appendicitis or undifferentiated abdominal pain routinely included oral contrast. The purpose of this study was to determine the incidence of repeat CT scans with oral contrast for the purpose of arriving at a final disposition in patients undergoing evaluation for abdominal pain. This analysis was also to determine if the general surgery service was willing and able to make accurate clinical determinations to operate without the use of oral contrast. METHODS: Consecutive abdominal CTs for nontraumatic abdominal pain were evaluated retrospectively over a 7-month period from January through July 2010. CT scans performed for evaluation of trauma were eliminated, as were cases in patients with known previous appendectomy or in cases in which appendicitis was not a consideration. Follow-up was by chart review over the ensuing 30 days for complications or need for surgery, which was not detected after the initial CT scan. The study was conducted at a teaching hospital, level I trauma center with an annual ED census of 99,000 visits. RESULTS: A total of 311 CT scans met the study criteria. No cases of appendicitis were missed. Two patients were operated on based upon inflammatory findings in the right lower quadrant, one with typhlitis, the second with possible inflammatory bowel disease versus typhlitis. In each case, the diagnosis was made by CT, but the surgery service chose to operate based on clinical findings. Sixteen (5.14%; 95% CI, 3.2%-8.2%) cases of acute appendicitis were accurately identified. A normal appendix was visualized in 125 (40.2 %; 95% CI, 34.9-45.7) patients. No patients (0%; 95% CI, 0%-1.2%) required a repeat CT scan with oral contrast as part of the workup. On 30-day follow-up by chart review, no (0%; 95% CI, 0%-1.2%) significant surgical problems were identified, and no cases of missed appendicitis were identified. CONCLUSIONS: Abdominal CT scan without the use of oral contrast is accurate to allow for appropriate decision making by emergency physicians and general surgeons. In our series, no patients required repeat scanning. Further assessment by larger studies is appropriate.

Pseudoseizures in a preadolescent: does this case have a bite?

We report a preadolescent girl with acquired complete heart block most likely caused by viral myocarditis. The diagnosis was supported by endomyocardial biopsy and several immunohistological panels. A temporary pacemaker was used, and the child responded well to therapy with full recovery of cardiac conduction.

How well do emergency physicians document confirmation of endotracheal tube placement?

The authors' goal was to determine the rate at which emergency physicians document confirmation of endotracheal tube (ET) placement. The study was conducted in a 60 000-visit emergency department (ED) of an urban tertiary referral hospital. The authors' airway registry database was used to identify patients requiring airway management; 433 patients met study criteria, 281 (65%) were intubated in the ED, and 152 (35%) were intubated prior to arrival. ET confirmation was documented for 270 (96%) patients intubated in the ED and 52 (34%) patients intubated before arrival (P < .0001).The rate was higher for patients intubated by emergency medical services (40/64 [63%]) than for interhospital transfers (12/88 [14%]) (P < .0001). Documentation of ET placement has implications for patient care and safety. This study indicates that educational interventions are warranted to improve physicians' awareness of the importance of documenting correct tube placement.

A case of renal artery thrombosis with renal infarction.

Renal artery thrombosis is a rare, but serious and often misdiagnosed, condition. Emergency physicians and other physicians need to consider this diagnosis in unexplained flank pain, especially in patients with risk factors for this disease. In this case report, the authors review a case of renal infarction caused by renal artery thrombosis in a patient with risk factors for thrombosis but no previous history of thromboembolism. A review of scholarly articles was performed and the case is discussed in the context of the current knowledge of this condition. Common presenting symptoms, features of the history and risk factors will all be discussed herein. Diagnostic evaluation of flank pain in the setting of the suspicion of renal infarction will be discussed, including the modalities of high-resolution computed tomography, renal angiography, scintography and ultrasound. Acute management and prognosis will also be discussed.

Platelet aspirin resistance in ED patients with suspected acute coronary syndrome.

BACKGROUND: Platelet aspirin resistance is reported to be as high as 45%. The prevalence of emergency department (ED) platelet aspirin resistance in suspected acute coronary syndrome (ACS) is not described. Our purpose was to determine the prevalence of platelet aspirin resistance. METHODS: We determined platelet aspirin resistance in a convenience sample of ED suspected ACS patients. Eligible patients had longer than 10 minutes of chest pain or an ischemic equivalent. Two hours after receiving 325 mg of aspirin, blood was assessed for platelet function (Accumetrics, San Diego, CA). Definitions are as follows: aspirin resistance, at least 550 aspirin reaction units; positive troponin T, greater than 0.1 ng/mL; significant coronary lesion, at least 70% stenosis. The composite end point was prospectively defined as a 30-day revisit, positive cardiac catheterization, or hospital length of stay (LOS) longer than 3 days. RESULTS: Of 200 patients, 50.5% were male, 50.0% were black, troponin T was positive in 7.5%, cardiac catheterization was done in 10.5%, and 33.3% had a significant stenosis. Final diagnoses were noncardiac in 83.4%, stable angina in 8.0%, and unstable angina in 8.5%. Overall, 6.5% were resistant to aspirin; and high-risk patients trended to more aspirin resistance than non-high-risk patients (23.1% [3] vs 9.1% [17]; P value 95% confidence interval [CI], -0.0929 to 0.373). One-month follow-up found ED revisits in 12.5% of aspirin-resistant vs 4.9% of non-aspirin-resistant patients (95% CI, -0.114 to 0.182) and rehospitalization in 12.5% of resistant patients vs 4.3% of nonresistant patients (P value 95% CI, -0.108 to 0.187). Although LOS was similar at index admission, if rehospitalized, LOS was 6.5 for aspirin-resistant patients vs 3.2 days in nonresistant patients (P < .0001). CONCLUSION: This first report of platelet aspirin resistance in patients presenting to the ED with suggested ACS finds that it is present in 6.5% of patients.

Airway registry: a performance improvement surveillance project of emergency department airway management.

The aim of this study was to determine if use of a standardized airway data collection sheet can survey airway management practices in an emergency department. Success rates and trends from the authors' facility have been benchmarked against the National Emergency Airway Registry (NEAR). This study included all patients requiring invasive airway management during a 21-month period (July 1, 2005, through March 31, 2007). An audit form was developed and implemented to collect data on intubations. During the study period, 224 patients required invasive airway control. Of all airways managed by emergency medicine residents, the intubation success rate was 99% (200/203; 95% confidence interval [CI] = 96%-100%), with 3% of those (6/203; 95% CI = 1%-6%) requiring more than 3 attempts; 3 patients (1%; 95% CI = 0%-4%) could not be intubated and required a surgical airway. Use of an airway registry based on the NEAR registry as a benchmark of rates and types of successful intubation allows comparison of airway practices.

Cases from the Cleveland Clinic: cerebral venous sinus thrombosis presenting to the emergency department with worst headache of life.

A 31 year old woman presented with the worst headache of her life and was diagnosed with cerebral venous sinus thrombosis (CVST) by routine unenhanced computed tomography (CT) scan, subsequently confirmed with magnetic resonance imaging (MRI) and magnetic resonance venography (MRV). Awareness of this less common cause for acute neurological presentation in the Emergency setting is important; the imaging characteristics of CVST are reviewed.

Venous thromboembolism prophylaxis in hospitalized heart failure patients.

BACKGROUND: Venous thromboembolism (VTE) is a concerning problem for hospitalized heart failure (HF) patients. Current recommendations are that all hospitalized New York Heart Association Class III or IV HF patients should receive VTE prophylaxis. Our purpose was to describe the rate of use and the characteristics of patients receiving VTE prophylaxis in the Acute Decompensated Heart Failure National Registry (ADHERE). METHODS AND RESULTS: HF hospitalization episodes in ADHERE were analyzed. Patients were excluded from analysis if they were receiving Coumadin or intravenous heparin, had elevated troponin levels, underwent cardiac catheterization or dialysis before or during hospitalization, or were initially admitted to the intensive care unit. VTE prophylaxis was defined as low-molecular-weight or subcutaneous unfractionated heparin administered at any time during hospitalization and intravenous vasoactive therapy was defined as any inotrope, inodilator, or vasodilator. Chi-square, analysis of variance, and Wilcoxon tests were used for univariate and multivariate analyses. Logistic regression was used to evaluate outcomes. A total of 155,073 entries were evaluated, with 71,376 eligible for VTE prophylaxis; 21,847 (31%) received VTE prophylaxis. VTE prophylaxis patients were more often African American (28% versus 21%) or admitted from the emergency department (84% versus 79%), compared with those who did not receive VTE prophylaxis (both P < .0001). Medical history and initial presentation characteristics were similar, except edema, which was more likely in VTE prophylaxis patients (71% versus 66%, P < .0001). Patients receiving VTE prophylaxis more often received an intravenous vasoactive agent (23% versus 18%), angiotensin-converting enzyme inhibitor (61% versus 54%), or beta-blocker (63% versus 58%) during their hospitalization and were more likely discharged on an angiotensin-converting enzyme inhibitor (53% versus 49%) or beta-blocker (57% versus 54%) than non-VTE prophylaxis patients, all P < .0001. VTE prophylaxis patients were more often admitted to the intensive care unit (4.8% versus 2.5%, P < .0001) and had longer median hospital stays (4.2 versus 3.8 days, P < .0001). Mortality was similar between cohorts (3.0% versus 2.9%, P = .69). CONCLUSIONS: Despite recommendations that all hospitalized New York Heart Association III and IV CHF patients receive venous thromboembolic disease prophylaxis, less than one third of eligible patients receive this guideline recommended therapy.

Diabetic muscle infarction: a rare complication of advanced diabetes mellitus.

Diabetic muscle infarction is a rare complication of diabetes mellitus first described in 1965. It typically arises in patients with long-standing diabetes mellitus who have complications of the disease, including nephropathy, retinopathy, and neuropathy. It typically presents with acute onset of thigh pain with an associated palpable tender mass. Recurrent episodes in the same or opposite limb are common. Laboratory evaluation does not generally show any consistent abnormality except for poor glucose control. Histologic features of diabetic muscle infarction consist of large areas of muscle necrosis and edema. Magnetic resonance imaging (MRI) findings in patients without clinical evidence of infection may be typical enough to make tissue biopsy unnecessary. In the appropriate clinical setting, MRI may obviate invasive testing and is the preferred imaging modality. Treatment is supportive with analgesics, rest, and immobilization.

Elevated serum cardiac markers predict coronary artery disease in patients with a history of heart failure who present with chest pain: insights from the i*trACS registry.

The significance of a history of heart failure (HF) in patients presenting with acute coronary syndromes and elevated cardiac markers is unclear. The authors performed an analysis of patients enrolled in the Internet Tracking Registry of Acute Coronary Syndromes (i*trACS). Cardiac marker measurement and cardiac catheterization were performed in 1174 patients. Of these, 116 (9.9%) had heart failure (HF). Coronary artery disease (CAD) was found in 61 (52.6%) patients in the HF group and 581 (54.9%) in the group without HF. In the non-HF cohort, positive markers occurred in 306 patients, in whom 217 (70.9%) had CAD at catheterization. In the HF subset, 24 patients had positive biomarkers and 15 (62.5%) had CAD. A history of HF did not lessen the likelihood of CAD as evidenced by angiography and does not diminish the utility of cardiac markers in diagnosing acute coronary syndromes.

An overview of non-cardiac cocaine toxicity.

Cocaine use in the United States continues to be a significant problem. Cocaine use is responsible for approximately 143,000 Emergency Department visits annually. The cardiac effects of cocaine are well known and much is written on this topic; this is beyond the scope of this article. Cocaine use is also responsible for a variety of non-cardiac, systemic complications, which it is our purpose to review. Multiple systemic effects of cocaine are seen with both acute and chronic use. These systems include: psychological and psychiatric, neurological, renal, pulmonary, gastrointestinal, obstetrical, and otolaryngological.

Urine protein as a rapid screen for renal function in the ED: can it replace serum creatinine in selected patients?

Many radiology departments are unwilling to perform studies that require contrast administration to adult emergency department patients over the age of 35 without having a documented serum creatinine concentration of less than 2.0 mg/dl within a week of the study. Significant diagnostic delays may ensue waiting for this serum test. The present study was performed to determine whether a negative urine protein test, obtained by dip testing, will serve as a marker for a serum creatinine concentration below 2.0 mg/dl in emergency department patients who give no history of a disease which potentially could cause renal insufficiency. Emergency patients aged 35 years or more presenting to a university hospital who did not volunteer a history of hypertension, diabetes mellitus, multiple myeloma, or systemic lupus erythematosus in triage were enrolled. Only patients with a negative urine protein test whose serum creatinine was tested for other reasons were included. Of the 310 patients who had no protein in their urine and no history of disease which potentially could cause renal insufficiency, none had a serum creatinine concentration greater than 2.0 mg/dl (mean=0.82 mg/dl, SD 0.28). Ages ranged from 35 to 96 years (mean=59.7 years, SD=17.5). All patients would have qualified for a contrast load for contrast computed tomography studies or for intravenous pyelogram. In patients who do not have a known history of hypertension, multiple myeloma, systemic lupus erythematosus, diabetes mellitus, or specific renal disease, urine dip testing for protein in the emergency department may be a rapid and safe screen for imaging studies requiring contrast without having to await serum creatinine testing.

Head injury: which patients need imaging? Which test is best?

Some patients with head injuries definitely need to undergo an imaging study--usually computed tomography (CT). Most, however, are in a category of "apparently mild" injury, and controversy continues about which of them need to undergo imaging studies to rule out intracranial injuries.